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If you meet the criteria as priority group 1A or 1B, as defined by the Department of State Health Services, you may pre-register with the Department of Public Health, using the form below, to receive the COVID-19 vaccine as available to DPH. You will be placed on a waiting list and will be contacted (phone, email, or text) when vaccines become available on a first come, first serve basis.

Please check your Inbox and Junk/Spam email folders for the confirmation email containing a copy of your form.‚Äč

Be aware this may take several weeks due to limited supplies.

Name

Full Address

Is your employer enrolled as a COVID-19 vaccine provider?

What statement best describes your daily work?

Do you consent sharing the information provided with COVID-19 vaccine providers to get the vaccine?